Prime’s analytics uncovers the hidden ups and downs behind the flat drug trend for MS DMDs

Insights from integrated medical and pharmacy claims show a big upswing in one drug on the medical side offset by savings from a generic on the pharmacy side

The overall trend for the disease-modifying drugs (DMDs) that treat multiple sclerosis (MS) has been flat. But Prime’s analysis of the integrated medical and pharmacy claims for those DMDs  reveals hidden insights.  

Prime identified 14 MS DMDs in medical and pharmacy claims by Generic Product Identifiers (GPI) and Healthcare Common Procedure Coding Systems (HCPCS). The study also used diagnosis codes for MS, because some of these drugs are used to treat other autoimmune conditions. After eliminating outliers, and claims for patients with other autoimmune conditions, the study could draw many insights from the data:

Overall MS DMD trend was indeed flat, but within the category, prices and volume fluctuated a lot. 

• The drug spend for Copaxone® went down; it is now generic and preferred under the pharmacy benefit. 
• Those savings were offset by increased spend for Ocrevus^®, a drug launched in 2017. Ocrevus is infused in a health care setting and billed under the medical benefit. 

More than 1 million people in the U.S. have MS. More than a dozen different DMDs (including two generics) are available to treat the disease. Across Prime’s 15 million commercial members integrated medical drug claims and pharmacy claims data, MS drug category ranks fourth in spend, behind the drug categories autoimmune, cancer and HIV.  

Since Prime’s last study of this population in 2018, four novel MS DMDs have received FDA approval and two generics came to market. 

The Institute for Clinical and Economic Review (ICER) published cost effectiveness guidelines in 2017. American Academy of Neurology’s (AAN) published treatment guidelines in 2018. Neither ICER or AAN have updated their guidelines since the four new drug approvals and two new generics.  

Current, real-world information about the changing DMD product mix and cost can help payers design effective formularies and care management programs. 

The study is important because drug therapies make up more than 80% of the total cost of treating MS. In fact, the list price for most DMDs are about $80,000 a year. The 2017 ICER report had indicated DMDs were overpriced relative to their benefits. 

Studies like this one can provide concrete real-world data to help prescribers make informed decisions on quality care. With two generic offerings already available, and biosimilars to treat MS on the way, plans and prescribers have opportunities for cost-savings in this category.